HWL-AAE Application for Exemption from Assessment

Form Approved OMB 0581-NEW

HARDWOOD LUMBER AND HARDWOOD PLYWOOD PROMOTION, RESEARCH AND INFORMATION BOARD

APPLICATION FOR EXEMPTION FROM ASSESSMENT

As stated in Section 1211.53 of the Hardwood Lumber and Hardwood Plywood Promotion, Research and Information Order (Exemption from assessments):

Hardwood lumber manufacturers, hardwood lumber products manufacturers, and hardwood lumber value-added products manufacturers with sales of any assessed product combined to be less than $2 million or hardwood plywood manufacturers whose annual sales are less than $10 million who desires to claim an exemption from assessments during a fiscal year as provided in Section 1211.53 shall apply to the Hardwood Lumber and Hardwood Plywood Promotion, Research and Information Board (Board), on a form provided by the Board, for a certificate of exemption. Such manufacturers shall certify that the manufacturer’s annual sales are below the exemption level for hardwood lumber or hardwood plywood for the fiscal year for which the exemption is claimed.

CERTIFICATION

(To Be Signed and Dated by Applicant)

I hereby certify that I manufactured and sold within the United States annual sales of hardwood lumber of less than $2 million or hardwood plywood of less than $10 million in 20XX (prior year). I therefore request a certificate of exemption from the Board for the year 20XX.

Signature ____________________________________ Date: __________________

Please Print

Name of Applicant: _________________________________________________

Company Name : _____________________________________________________

Street Address: ______________________________________________________

City: ________________________________ State: _________________________

Zip Code: ____________________ Telephone No. _________________________

Tax ID# or Business ID#: _________________________________

Please send your completed Certificate of Exemption Application with supporting documentation to verify prior year’s sales to the Hardwood Lumber Board at the following address:

Hardwood Lumber and Hardwood Plywood
Promotion, Research and Information Board

Street

City, State Zip

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat. 1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Business Identification Number is mandatory, and will be used to determine affiliation or entity identification.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-NEW. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

HWL-AAE (06/12)